Theory Of Planned Behaviour Essay, Research Paper
The Theory of Planned Behaviour: Nurses Attitudes towards Older Patients
Edmund Fitzgerald O Connor 9724709
ABSTRACT
The Theory of Planned Behaviour was tested in a study for its ability to predict intention to behave in specific ways towards older patients. There were 172 subjects from 3 Scottish universities, Napier, Edinburgh and Abertay Dundee. The results gained from a questionnaire suggest that the Theory of Planned behaviour can be used to predict behavioural intentions of nurses when working with older patients. Nurses intention to behave was predicted by their attitudes mostly, perceived behavioural control also carried a significant beta weight although social norms were found to be non significant. The underlying beliefs of attitudes, subjective norms and perceived behavioural controls were also investigated in terms of expectancy value models. Nurses with positive attitudes towards older patients were found to hold patient orientated values, and job satisfaction, more important than other relevant values. Nurses are also more motivated to comply with senior staff that may share their positive attitudes also. One consequence of the present findings is that greater levels of support by senior staff and ways of increasing job satisfaction will improve the levels of care and treatment for older patients.
Introduction
Last year, for the first time ever, the developed countries of the world had more people aged 60 and over than youths aged 14 and under. For the world as a whole, the same will be true by the year 2043. The percentage proportion of older people in Western Europe is predicted to increase by 14.8%, 8.8 in Japan and 2.7% in the U.S.(U.S Census bureau).
Two major forces drive the shift in age distribution. First, birth rates are declining in most parts of the world, but especially in the industrialized nations. and second, life expectancy is increasing almost everywhere. The U.K is a prime example of this phenomenon. In 1999 16 % of the population was 65 and over (DOH 1999). With the advent of new medicine and treatment for more and more illnesses and diseases the trend will increase. The implications of a human population that is both growing and aging are numerous and worrying. Advances in medical science, nutrition and fitness, and even bioengineering point to the day when many human beings will have the option of living well past the age of 100 (CSIS global initiative 99). The elderly have been for a long time the greatest users of healthcare (Lefebre et al. 1979). It can be inferred that this demand will continue to rise as the elderly population does. Nearly half of the NHS expenditure in 1999 was spent on the care of the over 65 this equates to 5.21 billion pounds(DOH 1999). From hospital beds to prescriptions the elderly were responsible for the greater share of the cost. In the front line of healthcare are nurses, who play a primary role in providing support and provision The perception and attitudes of these primary caregivers will greatly affect the response to the growing problem. It has previously been suggested that these caring services will be stretched to breaking point in future (Martin et al. 1988; Redfern, 1991).
Past research on attitudes of nurses towards the elderly has looked at the many different facets of primary nursing care of the elderly. At one end of the spectrum Robb (1967) highlighted examples of cruelty and abuse within the care of the elderly. Similarly in the USA Stannard (1973) showed that institutionalised cruelty existed on both sides of the Atlantic. Both papers are not con but one only needs to look in the recent press to see examples of systematic abuse and negative attitudes. Harold Shipman was convicted of murdering 15 elderly patients in his care, similarly a nurse was convicted of the murder of 3 elderly patients. Examples such as these, taken with evidence of an increasing elderly population, show that the need to understand the polarity of care workers attitudes is pressing
The question of which are the right attitudes towards the elderly has been a discussion point in the past. This idea and the study of current attitudes of care workers and how they have been formed has been the starting point of the majority of work within this field. Looking first at the idea of the right attitude Irvine (1970) suggested that the right attitude towards the elderly should be constructed from acceptance, respect, sympathy, and the ability to encourage. But the fundamental construct of the right attitude has been brought into question by many. Ingham and Fielding question whether there is a single right attitude suggesting that this is dependant on institutions aims and the perception of older people as individuals. Institutions are more concerned with smooth running than the needs of individual patients. However this philosophical approach is of little help when addressing the problem and in studies which show stereotyping and malcontent in working with the elderly, discussion on the rightness of right attitudes has proved of little use.
Care of the elderly has for some time been an unpopular field within healthcare (Ray et al., 1987; Solomon & Vickers, 1979; Mutschler, 1971). Past research highlighted the reluctance to work with older patients in hospitals and nursing homes (Campbell, 1971; Gillis, 1973; Gunter,1971) Why should this be the case even when the elderly are recognised as the group most in need, in society (Hardie, 1975)? Psychologists have looked towards stereotyping and ageism for possible answers. Ageism, a term first coined by Butler (1969), is a process of systematic stereotyping of, and discrimination against people because they are old (Butler & Lewis 1975 p117). Ageism and stereotyping has been developed as a possible reason for the negative perception and behaviour to the elderly. Not all research has found comparable results. Schoenfeild (1982) and Treharne (1990) suggested that in fact there is no evidence to suggest negative attitudes towards the elderly exists. However the majority of research has shown negative stereotyping of the elderly (Levin, 1988; Ray et al., 1987). It has been argued that attitudes held by professional workers such as nurses can directly determine the quality of care given to old people (Wells, 1980; Fielding,1986; Armstrong-Esther et al., 1989).
The bulk of research on nurses attitudes towards the elderly has focused on the level of training and experiences of respondents and how these impacted on their attitudes. A short period of training or intervention has resulted in increases in positive attitudes towards the elderly (Gunter, 1971; Robb, 1979; Tobiason et al., 1979), the majority of this work focusing on nurses. Snape (1986) however found contrary evidence. Student nurses who had been training for 2-3 years held more negative attitudes than recently enrolled nurses. Snape suggested that this was due to the absence from education, of extra directly specific material to do with the elderly. Other variables such as characteristics of the nurses and patients have been studied including age race, sex, and degree of care needed. On the subject of degree of care studies have shown that the greater the dependency of a patient the greater the negative attitudes shown by the nurse (Fielding, 1979). The improvements mentioned above (Gunter, 1971; Robb, 1979; Tobiason et al., 1979) have mostly come from a positive starting level. Some research has shown negative attitudes but the majority has shown neutral to positive attitudes (Slevin, 1991). One must first look at the methodological rigour when approached with this contradiction. One answer to this problem is that throughout the different studies there have been wide ranges of methodologies, which can suggest difficult in drawing direct comparison.
The majority of the previous studies have looked at attitudes of nurses and inferred the level of care associated. (Wells, 1980; Fielding, 1986; Armstrong-Esther et al., 1989) Other studies have tried to translate those attitudes into an intention to behave. Study of actual behaviour is problematic in certain contexts, and few have attempted this convincingly. Put together, the past research offers a confused mosaic not quite covering every facet of a complex question. Previous research has not attempted to separate out and explain intention to behave from attitudes and seems to miss out completely other influencing factors. Past research shows that attitudes although fundamental, are not the only predictive factor in explaining behaviour (Wicker, 1969; Kraus, 1995). In the present study an investigation into nurses attitudes towards the elderly will focus on the theory of reasoned action as a framework to predict an intention to behaviour and hence the reason for that behaviour.
Attitudes
The “attitude” construct received its first serious attention from Darwin in 1872. Darwin defined attitude as a motor concept, or the physical expression of an emotion. For early psychologists, “attitude” was an emotion or thought with a motoric (behavioural) component. In some cases, the motoric component was sub-vocal speech; in other cases, gross behaviour, such as postural change, was of interest. Beginning in the 1930’s, psychologists began to argue actively about what components should comprise the attitude concept. Although there was agreement that all attitudes contain an evaluative component, theorists disagreed about whether beliefs (cognitions) and behaviours should be included as part of the attitude concept. The prevailing view among cognitive social psychologists was that “attitude” has both affective and belief components and that attitudes and behaviour should be consistent; i.e., people with positive attitudes should behave positively toward the attitude object.
LaPierre s seminal experiment (1934) involving a Chinese couple in the USA started a huge interest in behaviour prediction. There is great difficulty in directly researching behaviour for pragmatic reasons. To secure a reliable measure of a given behaviour by one would have to use observation; the investigator would have to record the behaviour on a number of repeated occasions. Observers would have to be positioned at all locations where participants might engage in the given behaviour and record it frequently. Although not always of assured validity, self-reports are clearly more easily obtained. So attitude research often focuses on people s attitudes and intention to behave in a certain way, assuming that they are a proxy to behaviour. Attitudes are considered to be one of the most indispensable concepts in social psychology (Allport, 1935). Allport theorised that the attitude-behaviour relationship was not uni-dimensional as previously thought (Thurstone, 1929), but multi-dimensional. Attitudes were viewed as complex systems made up of the person s beliefs about the object, his feelings toward the object, and his action tendencies with respect to the object. Attitudes are one of the fundamental concepts in the theory of planned behaviour. Attitude towards a behaviour is the amount to which the performance of the behaviour is positively or negatively valued. Fishbein and Ajzen (1975, 1980) carried out some of the most influential research within this area of social psychology. Fishbein and Ajzen (1975, 1980) assumed that individuals are usually quite rational and make systematic use of information available to them. People consider the implications of their actions before they decide to engage or not engage in a given behaviour. They also pointed out that to measure the effect of attitudes one must be specific. La Pierre for instance was asking restaurant owners a general attitude towards Chinese people rather than attitudes towards a well dress couple accompanied by a smart westerner. They argued that attitudes must be specific to certain behaviour to have predictive effect.
Figure. 1 The Theory of Planned Behaviour
Fishbein and Ajzen (1975, 1980) assumed that individuals are usually quite rational and make systematic use of information available to them. People consider the implications of their actions before they decide to engage or not engage in a given behaviour” (Ajzen & Fishbein, 1980 p.167). After reviewing all the studies they developed a theory that could predict and understand behaviour an
Most social psychologists would agree that attitude formation involves cognitive or information processing. This idea is theorised in Fishbein & Ajzen s expectancy value model (1975). This model suggests that attitudes develop from the beliefs people have about the object of the attitude. Beliefs deal with the representation of the information this individual has about a specific object. Beliefs link a given object to an attribute; beliefs refers to the personal subjectivity concerning some aspect of his/her environment, i.e., the understanding a person may have about the world. Also, beliefs consider the subjective probability of a relationship between the given object of the belief and another object, value, concept, or attribute. Beliefs are formed as soon as an object is linked to an attribute. In the case of attitudes concerning behaviour beliefs link the attitude with a certain outcome. Although a person may hold a great many behavioural beliefs only a relatively small number are readily accessible at any time. The model goes on to state that by combining these accessible beliefs and the subjective values of the expected outcome of the behaviour in question you can determine the attitude towards the behaviour. This can be shown in the following equation.
N
AB = biei
i = 1
Where:
AB = individual’s attitude toward the behaviour
b = Beliefs the individual has about the fact that performing the behaviour B leads to a consequence or outcome i
e = evaluation of the outcome I
i = the specific belief number, from 1 to N
An important note about the expectancy value model is that the beliefs concerned must be of a salient nature and must be elicited from the respondents themselves.
The normative component of the theory deals with the influence the social environment may have on behaviour. Subjective Norms refers to an individual’s perception about his peers, family or friends opinions and how this perception influences him in whether or not he performs a specific behaviour. The model proposes that the general subjective norm (SN) can be obtained by adding the results of each multiplication between the person’s expectations regarding the group he considers important to him, i.e., his normative beliefs (NB), and his motivation to comply (MC) with each of the referent group. Similarly as with behavioural beliefs (precursor to attitudes), normative beliefs refer to the perceived behavioural expectations of important referents salient to the behaviour being investigated. Motivation to comply is the extent to which the subject wants to comply with the referents.
This formulation is presented in the following equation:
n
SN = (NB) i (MC)i
i = 1
Where:
SN = individual’s Attitude toward the Behaviour
NB = normative belief
MC = Motivation to Comply
i = the specific belief number, from 1 to N
The model has been used in many attitude studies in the past as a framework for prediction of behaviour intention (Conner & Sparks, 1996; Godin & Kok, 1996; Schifter & Ajzen, 1985; Terry, Gallois & McCamish, 1993). The Theory of Reasoned Action subsequently was refined to include a third controlling factor on a person s intention to behave. Perceived behavioural control was added as studies indicated that when subjects did not have volitional control or perceived volitional control these variables input into the model returned a greater degree of confidence and success in the theory. Perceived behavioural control was conceptualised as a person s expectancy of the ease or difficulty of performing the intended behaviour (Ajzen, 1988).
Perceived behavioural control is assumed to again be preceded by beliefs, in this case control beliefs. These relate to the perceived presence of factors that may facilitate or impede performance of behaviour. The control beliefs may be based on past experience or influence by second-hand information. The strength of each belief is weighted by the perceived power of the control factor. The products are aggregated in the following equation.
n
PBC = ci pi
i = 1
Where:
PBC = individual’s Perceived behavioural control
c = Control belief
p = perceived power
i = the specific belief number, from 1 to N
Ajzen and Madden (1986) confirmed the hypothesis that the incorporation of the behavioural control component allows for more accurate prediction of behaviour such as students class attendance and course achievements, compared with the original version of the theory of reasoned action. The advent of the Theory of Planned Behaviour does not render the Theory of Reasoned Action obsolete. However when behaviour is in some way deemed to be under volitional control of the subject then the Theory of Planned Behaviour would create a more accurate account. Although, each facet of the theory is important studies have shown that according to the research domain, each has a greater or lesser influence. Out of 19 Theory of Planned Behaviour studies Ajzen himself looked at only 9 were found to have significant influence from the subjective norms, and so this suggests that the effect of prediction is specific (Ajzen, 1991). Attitudes were found to have the most influence on the intention to behave.
With Ajzen s theory came a number of criticisms and alternate theories. Psychologists such and Bentler and Speckart (1979, 1981) highlighted the importance of habits when attempting to predict and explain people s intention to behave. Other variables investigated and found to have influencing behaviour are the experienced moral obligation to show certain behaviour or the relevance of this behaviour for self-identity outcomes (Gorsuch and Ortberg, 1983; Granberg and Holmberg, 1990). Alternate structures have been hypothesized. Fazio s MODE model (motivation and opportunity as determinants of how attitudes influence behaviour) was suggested as Fazio believed that the Theory of Reasoned Action was only useful when dealing with situations where people are highly motivated and capable of thinking deliberately about the attitude and/or the behaviour relevant to this attitude (Fazio, 1990) The crux of this idea was that in a situation were there is a lack of motivation or reasonable ability to access decision on an attitude behaviour dependant issue then highly accessible attitudes will influence behaviour as they affect the persons perception and judgment of the situation. The assumption of intention to behave was critised by many including Eagly and Chaiken (1993). They wrote the concept of intentions remains underdeveloped in the reasoned action model. Intention might . . . be conceptualized as a continuum running from vaguely formulated thoughts about future behaviour to clear-cut plans that one is going to engage in a particular behaviour at a particular point in time (p. 185). Simon (1981) questioned the assumption of human rational decision-making, which Azjen postulated was one of the assumptions the Theory of Reasoned Action took into account. According to Simon given the capacity limitations of human information processing, people do not try to optimise outcomes through their behavioural decisions but are in general satisfied with any outcome that is above a subjective level of aspiration . Individuals strive not for maximum utility but for satisfying outcomes that can be far short of a theoretically achievable maximum.
Interesting evolutions of the TRA and TPB have been suggested by a number of psychologists. These lie in the expansion of the original premise Azjen made about the self. In these recent theoretical re-formulations, it is argued that the self can be deconstructed into a number of different arenas, such as private self, personal self, and interpersonal self and other broader social identities. The private self can be seen in terms of one s own experiences and personality traits. The interpersonal self can be broadly regarded as a form of social identity and self-categorisation, within a group scenario. The foundations of the Theory of Reasoned Action still hold in these alternate proposed ideas. Social norms can be translated into the vernacular of social influence in which a group exerts social pressure upon the subject to conform to a given social ideal or behaviour. These ideas provide ways of explaining the varying degrees of influence both attitudes and norms affects one intention to behave. For example if a behaviour (assuming the direct correlation with intent) is the product of a situation with personal relevance to the individual then attitudes will play a larger role than the social norms. If the opposite is true and the situation is borne out from depersonalisation then the norms are the better indication of intention.
Theory of Planned Behaviour and Health Care
The theory of Reasoned Action has been influential on a number of past studies focused on the attitudes of nurses (Carter & MacInnes ,1996; Hope ,1994; J Snape,1989). A number of studies across the breadth of healthcare have used the Theory of Reasoned Action and Theory of Planned Behaviour as support for their findings (e.g. Conner and Sparks, 1996; Godin, Valois, Lepage and Deshamais, 1992; Schifter and Ajzen, 1985; Terry, Gallois and McCamish, 1993). With the domain of nurse healthcare and their form of work it is unclear as of yet if attitudes or subjective norms are of greater influence. Past studies have perhaps wrongly taken this subjective theorization. There are arguments for both attitudes being more important due to the large proportion of interpersonal involvement on the part of a nurse. Subjective norms can also claim to have a greater influence due to the structure of our healthcare system as a responsibility hierarchy. The Theory of Planned behaviour has not been used before to model nurses behaviour in respect to elderly patients. Previously the assumption has that nurses have volitional control whilst working on a ward with patients. There are however a myriad of nonvolitional influences, which may well have a significant effect on a nurses behaviour. These nonvolitional factors such as the working environment and hospital policy, which in a hieratically organized environment such as a hospital may play an influential role. Past research in health care has often over looked these variables. Certainly the high level of interpersonal care and contact in nurses day-to-day work is directly influenced by the nurses own self identity (Farley, Lehmann and Ryan 1981), so therefore attitudes are expected to be significantly predictive of behavioural intentions. Perceived behavioural control has been shown to be of greatest influence when a person has previous experience and knowledge of the target behaviour and environment ( Bentler & Speckart,1979; Fredricks & Dossett, 1983; Manstead et al. 1983). Gerontology is a large specialist field in healthcare and a large proportion of nursing education from the outset of 1st year training. The theory of planned behaviour offers a better architecture in which to incorporate these influencing factors.
Hypotheses
H1 = The theory of Planned Behaviour can be used to predict Nurses intentions to behave towards elderly people.
H2 = Behavioural beliefs and evaluations directly correlate with attitudes.
H3 = Normative beliefs and evaluations directly correlate with subjective norms.
H4 = Control beliefs and control power directly correlate with perceived behavioural controls.